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<br />J. subject or ballot title of petition/name of public official for recall <br /> <br /> <br />name of chief petitioner <br /> <br />phone number <br /> <br />address including zip code <br /> <br />name of chief petitioner <br /> <br />phone number <br /> <br />address including zip code <br /> <br />name of chief petitioner <br /> <br />phone number <br /> <br />address including zip code <br /> <br />J. signature <br />By signing this document I acknowledge that I am personally liable for any penalties imposed under ORS chapter 260, and <br />attest that the information on the form is true and correct. <br /> <br />treasurer's signature <br /> <br />date signed <br /> <br />chief petitioner's signature (optional) <br /> <br />date signed <br /> <br />for office use only <br /> <br />initials <br /> <br />committee 10 number <br /> <br />office number <br /> <br />date acknowledgment sent <br />